Fill and Sign the Telecommuting Checklist and Agreement Office Depot Form

Worksheet – Telecommuting Tasks 1. Does the space seem adequately ventilated? [ ] Yes [ ] No 2. Is the space reasonably quiet? [ ] Yes [ ] No 3. Are all stairs with 4 or more steps equipped with handrails? [ ] Yes [ ] No 4. Are all circuit breakers and/or fuses in the electrical panel labeled as to intended service? [ ] Yes [ ] No 5. Do circuit breakers clearly indicate if they are in open or closed position? [ ] Yes [ ] No 6. Is all electrical equipment free of recognized hazards that would cause physical harm (frayed wires, bare conductors, loose wires, flexible wires running through walls, exposed wires fixed to the ceiling)? [ ] Yes [ ] No 7. Are electrical outlets pronged (grounded)? [ ] Yes [ ] No 8. Are aisles, doorways, and corners free of obstructions to permit visibility and movement? [ ] Yes [ ] No 9. Are file cabinets and storage closets arranged so drawers and doors do not open into walkways? [ ] Yes [ ] No 10. Do the chairs appear sturdy? [ ] Yes [ ] No 11. Is the space crowded with furniture? [ ] Yes [ ] No 12. Are the phone lines, electrical cords, and extension wires secured under a desk or alongside a baseboard? [ ] Yes [ ] No 13. Is the office space neat and clean? [ ] Yes [ ] No 14. Are floor surfaces clean, dry, level, and free of worn or frayed seams? [ ] Yes [ ] No 15. Are carpets well secured to the floor and free of frayed or worn seams? [ ] Yes [ ] No 16. Is there a fire extinguisher in the home, easily accessible from the office space? [ ] Yes [ ] No 17. Is there a working (test) smoke detector within hearing distance of the work space? [ ] Yes [ ] No 18.The employee agrees to arrange for an energy audit of the home by the local utility company and fire safety inspection by the local fire department within 30 days of the signing of this agreement, provided they can be accomplished free of charge. [ ] Yes [ ] No 19. We agree that in our opinion this is an acceptable home office space That allows the employee a reasonable opportunity to meet the job requirements as a telecommuter. [ ] Yes [ ] No Site Inspected By: _______________________ _____________________________ (Printed Name of Employee) Date: ________________________ __________________________ (Signature of Employee)